Massey Insurance

Name:

Phone Number:

Certificateholder Name & Address (you must include the full name and mailing address or the certificate cannot be issued):

Fax Number:

Please specify which vehicle this applies to:

Your insurance company may require additional documentation in order to issue this form, please list your contact information so we may reach you should we need any further information.

Would you prefer certificate be sent by: Fax Mail

Is an additional insured endorsement required?: Yes No

Is a loss payee endorsement required?: Yes No